Application Ambulatory Surgical Centers by NDfLRGk

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									                                                                   APPLICATION CHECKLIST
                                                                Health Care Licensing Application
                                                                   AMBULATORY SURGICAL CENTER

Applicants must include the following attachments as stated in Chapters 408, Part II, and 395, Florida Statutes (F.S.), and Chapters
59A-35 and 59A-5, Florida Administrative Code (F.A.C). Applications must be received at least 60 days prior to the expiration of the
current license or effective date of a change of ownership to avoid a late fine. The application will be withdrawn from review if all
the required documents and fees are not included with this application or received within 21 days of an omission notice.
All forms listed below may be obtained from the website: http://ahca.myflorida.com/Publications/Forms/HQA.shtml. Send completed
applications to: Agency for Health Care Administration, Hospital and Outpatient Services Unit, 2727 Mahan Drive, Mail Stop 31,
Tallahassee, FL 32308.


A.   Initials, Renewals and Change of Ownership Applications must include:

NOTE TO ALL APPLICANTS: The Agency will verify that all applicants, licensees and controlling interests subject to Chapters 607, 608 or 617, Florida
Statutes related to Business Organizations have complied with applicable Department of State registration and filing requirements. The principal and
mailing addresses submitted with any application must be the same as the addresses that appear as registered with the Department of State, Division of
Corporations.


     The biennial licensure fee ($1,542.00) - Please make check or money order payable to the Agency for Health Care
     Administration (AHCA). All fees are nonrefundable. Additional fees may apply. Refer to Section 2 of this application.

     Health Care Licensing Application, Ambulatory Surgical Centers , AHCA Form 3130-2001. NOTE: All Agency correspondence will
     be sent to the mailing address provided in Section 1 of the application. If an applicant or licensee is required to register or file with
     the Florida Secretary of State Division of Corporations, the principal, fictitious name and mailing address provided in Section 2 of
     this application must be the same as the information registered with the Division of Corporations as provided in section 59A-
     35.060(4), Florida Administrative Code.
     Health Care Licensing Application Addendum, AHCA Form 3110-1024 - Complete the information that is applicable, write “NA” on
     the items that are not applicable, sign, date and send with the application (refer to Sections 3 & 4 of the application for further
     details).
     A copy of the most recent accreditation report if the hospital is accredited by an accrediting organization.
     A fingerprint card for a Level 2 background screening for the Administrator and Chief Financial Officer is required every 5 years.
     Please check all boxes below that apply to this application:

           A fingerprint card for a Level 2 background screening was submitted through the Agency’s Background Screening Unit within
           the previous 5 years for the       Administrator and/or     Chief Financial Officer.

           A fingerprint card for the    Administrator and/or      Chief Financial Officer is included with this application along with
           the screening fee of $43.25 per screening. Information on how to properly fill out a fingerprint card may be found on the
           Agency’s website: http://ahca.myflorida.com/MCHQ/Long_Term_Care/Background_Screening/index.shtml.

           A Level 2 screening was submitted electronically on the Agency’s Background Screening website:
           http://ahca.myflorida.com/MCHQ/Long_Term_Care/Background_Screening/logon.shtml .

           A Level 2 screening fingerprint card was submitted to the Agency’s Division of Medicaid as part of the Medicaid provider
           application for the     Administrator and/or      Chief Financial Officer.

         Proof of Level 2 screening within the previous 5 years for the         Administrator and/or       Chief Financial Officer from the
         Department of Children and Families, Department of Health, Agency for Persons with Disabilities or Department of Financial
         Services (if the applicant has a certificate of authority to operate a continuing care retirement community) is included with this
         application. An Affidavit of Compliance with Background Screening Requirements, AHCA Form 3100-0008 is also enclosed.



B. Additional Information needed for INITIAL Applications:

     Proof of compliance with local zoning requirements.

AHCA Form 3130-2001, Revised July 2009                                                               Section 59A-35.060(1), Florida Administrative Code
INSTRUCTION CHECKLIST                                                       Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
     Proof of compliance with fictitious name registration, if applicable
     A copy of Articles of Incorporation, Organization or Partnership as registered with the Florida Department of State
     Proof of the licensee’s right to occupy the building such as a copy of a lease, sublease agreement, or deed.


NOTE: Proof of successful completion of the 100% physical plant survey conducted by the Agency’s Bureau of Plans and Construction is required.
This information is transmitted by an internal Agency memo, but may be supplied to the facility upon satisfactory completion of the 100% Plans and
Construction survey.




C. Additional Information needed for CHANGE OF OWNERSHIP Applications:

     Proof of the licensee’s right to occupy the building such as a copy of the lease, sublease agreement, or deed.
     Proof of compliance with fictitious name registration, if applicable
     A copy of Articles of Incorporation, Organization or Partnership as registered with the Florida Department of State
     Closing documents indicating the date of transfer of ownership signed and dated by all parties.
     A signed agreement to correct all outstanding deficiencies cited on the most recent life safety survey.

     A signed agreement to pay any outstanding payments owed to the Agency. The agreement must include who will pay and when
     payment will be made.




D. Change During License Period:
1. Request to add/decrease the number of Operating Room/Recovery beds:
     NOTE: Any remodeling or change to the physical plant requires prior approval from the Agency’s Office of Plans and Construction.


     Complete and submit sections 1, 2 and 8 through 10 of the Health Care Licensing Application, Ambulatory Surgical Centers,
     AHCA Form 3130-2001
       $25.00 fee for replacement license or reissue of license due to change during licensure period. Please make check or money
       order payable to the Agency for Health Care Administration (AHCA). All fees are nonrefundable


2. Request to change the name or address of provider:

     Complete and submit sections 1, 2 and 10 of the Health Care Licensing Application, Ambulatory Surgical Centers, AHCA Form
     3130-2001

       $25.00 fee for replacement license or reissue of license due to change during licensure period. Please make check or money
       order payable to the Agency for Health Care Administration (AHCA). All fees are nonrefundable




The Agency for Health Care Administration scans all documents for electronic storage. In an effort to facilitate this process, we ask that you please
place checks, money orders and fingerprint cards on top of the application and paperclip everything together. Please do not staple or bind
documents submitted to the Agency.




AHCA Form 3130-2001, Revised July 2009                                                                 Section 59A-35.060(1), Florida Administrative Code
INSTRUCTION CHECKLIST                                                         Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
                                                                                                  AHCA USE ONLY:

                                                                                                  File #:
                                                                                                  Application #:
                                                                                                  Check #:
                                                                                                  Check Amt:
                                                                                                  Batch #:



                                          Health Care Licensing Application
                                         AMBULATORY SURGICAL CENTER
Under the authority of Chapters 408 Part II, and 395 Florida Statutes (F.S.), and Chapters 59A-35 and 59A-5, Florida Administrative
Code (F.A.C.), an application is hereby made to operate an ambulatory surgical center as indicated below:


1. Provider / Licensee Information

A.     Provider Information – please complete the following for the ambulatory surgical center name and location.
      Provider name, address and telephone number will be listed on http://www.floridahealthfinder.gov/
License # (for renewal & change of ownership   National Provider Identifier (NPI)              Medicare # (CMS CCN)         Medicaid #
applications)                                  (if applicable)

Name of Ambulatory Surgical Center (if operated under a fictitious name, list that here)


Street Address

City                                                                    County                               State             Zip

Telephone Number                            Fax Number                  E-mail Address                           Provider Website


Mailing Address or       Same as above (All mail will be sent to this location)

City                                                                      State                       Zip

Contact Person for this application                                                      Contact Telephone Number

Contact e-mail address or        Do not have e-mail
                                                                 NOTE: By providing your e-mail address you agree to accept e-mail
                                                                 correspondence from the Agency


B.     Licensee Information – please complete the following for the entity seeking to operate the ambulatory
       surgical center.
Licensee Name (may be same as provider name above)                                         Federal Employer Identification Number (EIN)

Mailing Address or       Same as above

City                                                                     State                       Zip

Telephone Number                        Fax Number                                E-mail Address

Description of Licensee (check one):
         For Profit                                        Not for Profit                             Public
            Corporation                                       Corporation                               State
            Limited Liability Company                         Religious Affiliation                     City/County
            Partnership                                       Limited Liability Company                 Hospital District
            Individual                                        Other
            Other



AHCA Form 3130-2001, Revised July 2009                                                               Section 59A-35.060(1), Florida Administrative Code
Page 1 of 8                                                                Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
2. Application Type and Fees
Indicate the type of application with an “X.” Applications will not be processed if all applicable fees are not included.
All fees are nonrefundable.

        Initial Licensure
     Was this entity previously licensed as an Ambulatory Surgical Center in Florida?
                   YES                 NO
     If yes, please provide the name of the agency (if different), the EIN # and the year the prior license expired or closed:
      NAME:                                                               EIN #                              Year Expired/Closed:

         Renewal Licensure
         Change of Ownership                                                                   Proposed Effective Date:
         Change during licensure period                                                        Proposed Effective Date:
            Increase number of operating rooms and/or recovery beds
            Decrease number of operating rooms and/or recovery beds
            Name change of the facility
            Address change of the facility

                                                          Action                                                     Fee          TOTAL FEES

 LICENSE FEE (Initial, Renewal and Change of Ownership):                                                           $1,542.00     $

 Initial Licensure Survey Fee (initial applicants only)                                                              $400.00     $

 Change During Licensure Period/Replacement License                                                                  $ 25.00     $

 Level 2 Background Screening for Administrator                                                                      $ 43.25     $

 Level 2 Background Screening for Chief Financial Officer                                                            $ 43.25     $

                                                                   TOTAL FEES INCLUDED WITH APPLICATION:                         $

                 Please make check or money order payable to the Agency for Health Care Administration (AHCA)




3.       Controlling Interests of Licensee


AUTHORITY:
Pursuant to section 408.806(1)(a) and (b), Florida Statutes, an application for licensure must include: the name, address and Social
Security number of the applicant and each controlling interest, if the applicant or controlling interest is an individual; and the name,
address, and federal employer identification number (EIN) of the applicant and each controlling interest, if the applicant or controlling
interest is not an individual. Disclosure of Social Security number(s) is mandatory. The Agency for Health Care Administration shall
use such information for purposes of securing the proper identification of persons listed on this application for licensure. However, in an
effort to protect all personal information, do not include Social Security numbers on this form. All Social Security numbers must
be entered on the Health Care Licensing Application Addendum, AHCA Form 3110-1024.



DEFINITIONS:
Controlling interests, as defined in subsection 408.803(7), Florida Statutes, are the applicant or licensee; a person or entity that
serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or a
person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the
management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The
term does not include a voluntary board member.


AHCA Form 3130-2001, Revised July 2009                                                          Section 59A-35.060(1), Florida Administrative Code
Page 2 of 8                                                           Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
Voluntary Board Member, as defined in subsection 408.803(13), Florida Statutes, means a board member or officer of a not-for-profit
corporation or organization who serves solely in a voluntary capacity, does not receive any remuneration for his or her services on the
board of directors, and has no financial interest in the corporation or organization.

In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or
greater ownership interest in the licensee. Attach additional sheets if necessary.


A.        Individual and/or Entity Ownership of Licensee

                                                                                                                                         %
                                                                                                                    EIN
 FULL NAME of INDIVIDUAL or        PERSONAL OR BUSINESS ADDRESS                TELEPHONE NUMBER                                     OWNERSHIP
                                                                                                                 (No SSNs)
         ENTITY                                                                                                                      INTEREST




B.       Board Members and Officers of Licensee
                                                                                                                                         %
     TITLE                  FULL NAME                    PERSONAL OR BUSINESS ADDRESS                                               OWNERSHIP
                                                                                                        TELEPHONE NUMBER
                                                                                                                                     INTEREST
Director/CEO
President
Vice
President
Secretary
Treasurer
Other:



C.       Voluntary Board Members and Officers of Licensee
If the licensee is a not-for-profit corporation/organization, provide the requested information for each individual that serves as a
voluntary board member. Attach additional sheets if necessary.


              FULL NAME                                PERSONAL OR BUSINESS ADDRESS                                   TELEPHONE NUMBER




D.       Administration

                                                                            TELEHPONE
               TITLE                               NAME                                                             E-MAIL
                                                                             NUMBER

Administrator/Managing Employee

Chief Financial Officer


AHCA Form 3130-2001, Revised July 2009                                                         Section 59A-35.060(1), Florida Administrative Code
Page 3 of 8                                                          Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
4.       Management Company Controlling Interests

Does a company other than the licensee manage the licensed provider?

          If     NO, skip to section 5 – Required Disclosure.
          If     YES, provide the following information:

Name of Management Company                                          EIN (No SSN)                    Telephone Number / Fax

Street Address                                                                  E-mail Address

City                                                               County                           State                  Zip

Mailing Address or     Same as above

City                                                                                                State                  Zip

Contact Person                                 Contact E-mail                                       Contact Telephone Number




In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or
greater ownership interest in the management company. Attach additional sheets if necessary.




A.       Individual and/or Entity Ownership of Management Company
                                                                                                                                       %
      FULL NAME of                                                                                             EIN
                             PERSONAL OR BUSINESS ADDRESS              TELEPHONE NUMBER                                           OWNERSHIP
  INDIVIDUAL or ENTITY                                                                                      (No SSNs)
                                                                                                                                   INTEREST




B.       Board Members and Officers of Management Company
                                                                                                                                       %
                                                                                                             TELEPHONE
       TITLE                   FULL NAME                    PERSONAL OR BUSINESS ADDRESS                                          OWNERSHIP
                                                                                                              NUMBER
                                                                                                                                   INTEREST
Director/CEO
President
Vice President
Secretary
Treasurer
Other:



AHCA Form 3130-2001, Revised July 2009                                                         Section 59A-35.060(1), Florida Administrative Code
Page 4 of 8                                                          Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
C.      Voluntary Board Members and Officers of Management Company
If the management company is a not-for-profit corporation/organization, provide the requested information for each individual that
serves as a voluntary board member. Attach additional sheets if necessary.

                 FULL NAME                               PERSONAL OR BUSINESS ADDRESS                                 TELEPHONE NUMBER




5. Required Disclosure

The following disclosures are required:

A.    Pursuant to subsection 408.809(1)(d), F.S., the applicant shall submit to the agency a description and explanation of any
      convictions of offenses prohibited by sections 435.04 and 408.809(5), F.S., for each controlling interest.
Has the applicant or any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to
subsection 408.809(1)(d), Florida Statutes? (These offenses are listed on the Affidavit of Compliance with Background Screening
Requirements, AHCA Form #3100-0008.)                     YES                NO
        If yes, enclose the following information:
           The full legal name of the individual and the position held
           A description/explanation of the conviction(s) - If the individual has received an exemption from disqualification for the
           offense, include a copy


B.    Pursuant to section 408.810(2), F.S., the applicant must provide a description and explanation of any exclusions, suspensions, or
      terminations from the Medicare, Medicaid, or federal Clinical Laboratory Improvement Amendment (CLIA) programs.
Has the applicant or any individual listed in Sections 3 and 4 of this application been excluded, suspended, terminated or involuntarily
withdrawn from participation in Medicare or Medicaid in any state?          YES              NO
                   If yes, enclose the following information:
                   The full legal name of the individual and the position held
                   A description/explanation of the exclusion, suspension, termination or involuntary withdrawal.



C.    Pursuant to section 408.815(4), F.S., does the applicant or any controlling interest in an applicant have any of the following:
YES         NO        Convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a
                      felony under chapter 409, chapter 817, chapter 893, 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, within the
                      previous 15 years prior to the date of this application;

YES         NO        Terminated for cause from the Florida Medicaid program pursuant to s. 409.913, and not been in good standing
                      with the Florida Medicaid program for the most recent 5 years;

YES         NO        Terminated for cause, pursuant to the appeals procedures established by the state or federal government, from the
                      federal Medicare program or from any other state Medicaid program, have not been in good standing with a state
                      Medicaid program or the federal Medicare program for the most recent 5 years and the termination was less than
                      20 years prior to the date of this application.



AHCA Form 3130-2001, Revised July 2009                                                             Section 59A-35.060(1), Florida Administrative Code
Page 5 of 8                                                              Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
6.      Provider Fines and Financial Information

Pursuant to subsection 408.831(1)(a), Florida Statutes, the Agency may take action against the applicant, licensee, or a licensee which
shares a common controlling interest with the applicant if they have failed to pay all outstanding fines, liens, or overpayments assessed
by final order of the agency or final order of the Centers for Medicare and Medicaid Services (CMS), not subject to further appeal,
unless a repayment plan is approved by the agency.
Are there any incidences of outstanding fines, liens or overpayments as described above?          YES              NO
     If yes, please complete the following for each incidence (attach additional sheets if necessary):
          Amount: $          assessed by:          Agency for Health Care Administration Case #                         CMS
          Date of related inspection, application or overpayment period if applicable:
          Due date of payment:
          Is there an appeal pending from a Final Order?           YES               NO


                                   Please attach a copy of the approved repayment plan if applicable.




7.      Federal Certification

Does the provider participate in or intend to participate in the

     Medicare program?       YES      NO
     Medicaid program?       YES      NO


     If you plan to participate in Medicare:
     The Medicare Provider Application (CMS Form 855B) is available from the Medicare Administrative Contractor or on the Centers
     for Medicare and Medicaid Services (CMS) website at: www.cms.hhs.gov/cmsforms/. The form must be sent directly to the
     chosen fiscal intermediary for review.

     NOTE: The following forms must be attached to this application: CMS 370 (2 originals), CMS 377, Fiscal Intermediary Choice
     Form, HHS 690.


     If you plan to participate in Medicaid:
     Visit the Agency’s website at: http://ahca.myflorida.com/Medicaid/index.shtml in order to obtain information and an application for
     enrollment in Medicaid.




8.      Governing Body and Administrative Officers

Please provide the following:


                                                                                                        TELEHPONE
        TITLE                        NAME                                ADDRESS                                                  E-MAIL
                                                                                                         NUMBER
President of
Governing Body




AHCA Form 3130-2001, Revised July 2009                                                          Section 59A-35.060(1), Florida Administrative Code
Page 6 of 8                                                           Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
Please enter the information below for the licensed personnel on staff including the required positions of administrator, chief financial
officer, risk manager and patient safety officer. Include all licensed personnel such as physicians, nurses, technicians, and consultants.
Attach additional sheets if necessary.


                                                                                                                        FLORIDA LICENSE
              FULL NAME                              TITLE                               STATUS                         OR REGISTRATION
                                                                             (part-time, full-time, or contract)            NUMBER

                                            Patient Safety Officer                                                                N/A

                                            Risk Manager




9.        General Information

     A.   Bed Capacity
          Number of Operating Rooms:                 (do not include exam or procedure rooms)
          Number of Recovery Beds:




     B.   Accreditation
          The provider is accredited by:
              None                                Accreditation Association for Ambulatory Health Care
              The Joint Commission                American Association for Accreditation of Ambulatory Surgery Facilities

              The accreditation includes federal deemed status            Accreditation begins             and ends

              I understand that the complete accreditation report must be submitted to AHCA for review if the accreditation report is to
              be accepted in lieu of annual licensure inspections and such reports used to meet licensure requirements are considered
              public documents subject to disclosure per chapter 119, F.S.



AHCA Form 3130-2001, Revised July 2009                                                         Section 59A-35.060(1), Florida Administrative Code
Page 7 of 8                                                          Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml
   C.   Other Services

        Please check all that apply:

           X-ray provided on the premises or by contract in accordance with Chapter 404, F.S.
           Laboratory provided on the premises or by contract in accordance with Chapter 483, F.S.
        1. Please provide the applicable registration and license numbers(s):             ;                       ;              ;



   D.   Emergency Services

        Please provide the name and address of the hospital(s) providing emergency inpatient care (attach additional sheets if
        necessary):

                   Name of Hospital                                                         Address of Hospital




10.     Affidavit



I,                                       , hereby swear or affirm, under penalty of perjury, that the statements in this
application are true and correct. As administrator or authorized representative of the above named provider/facility, I
hereby attest that all employees required by law to undergo Level 2 background screening have met the minimum
standards of sections 435.04, and 408.809(5), Florida Statutes (F.S.) or are awaiting screening results.

In addition, I attest that all employees subject to Level 2 screening standards have attested to meeting the requirements
for qualifying for employment and agree to inform me immediately if convicted of any of the disqualifying offenses while
employed here as specified in subsection 435.04(5), F.S.




Signature of Licensee or Authorized Representative                         Title                                             Date



  RETURN THIS COMPLETED FORM WITH FEES AND ALL
  REQUIRED DOCUMENTS TO:

  AGENCY FOR HEALTH CARE ADMINISTRATION
  HOSPITAL AND OUTPATIENT SERVICES UNIT
  2727 MAHAN DR., MS 31
  TALLAHASSEE FL 32308-5407

  Questions?
  Review the information available at
  http://ahca.myflorida.com/ or contact the Hospital and Outpatient
  Services Unit at (850) 412-4549


AHCA Form 3130-2001, Revised July 2009                                                          Section 59A-35.060(1), Florida Administrative Code
Page 8 of 8                                                           Form available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

								
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